Limited impact of a top-down approach to improve enhanced recovery programme in French university hospitals: a before-after retrospective survey.

BACKGROUND: Enhanced recovery programme (ERP) after surgery needs development in Assistance Publique Hôpitaux de Paris (APHP). METHODS: A retrospective before-and-after study was performed in 2015 and 2017 on three surgical models (total knee arthroplasty (TKA), colectomy and hysterectomy) in 17 hospitals including 29 surgical departments. Data were collected in one control intervention (total hip arthroplasty (THA), gastrectomy and ovariectomy). In 2016, Massive Open Online Course on ERP and a day meeting information were developed by APHP. A national update on ERP was also organized by HAS and a regional professional partnership programme was started. Primary outcomes were length of stay (LOS) and complications after surgery. Data on ERP items were collected in the patients' chart and in anaesthetist and surgeon interview. Seventy percent application rate reflects application of ERP procedure. RESULTS: 1321 patient's files were analysed (812 in 2015 and 509 in 2017). The LOS (mean (SD)) is reduced by 1.6 day for TKA (2015, 8.7 (6.7) versus 7.1 (3.4) in 2017; p<0.001) but stable for colectomy and hysterectomy. Incidence of severe complications after surgery is unchanged in all types of surgical models. For TKA and hysterectomy respectively applied items of ERP (i.e. >70% application) increased respectively from 5 to 7 out of 17 and 16 in 2015 and 2017. For colectomy, they were stable at 6 out of 21 in 2015 and 2017. The mean application rates of ERP items stayed below 50% in all cases in 2017. The LOS was negatively correlated with ERP items' application when data collected in 2015 and 2017 were analysed together. CONCLUSION: ERP application did not significantly improved between 2015 and 2017 for three surgical models after an institutional information and diffusion of recommendations in 29 surgical departments of seventeen French University hospitals underlining the limit of a top-down approach.

[Nurse-led central venous catheter insertion, a review of a cooperation protocol]. / Pose de voie veineuse centrale par l'infirmier, retour sur un protocole de coopération.

Chemotherapy for cancer patients often requires a central venous catheter the insertion of which has previously been the exclusive remit of medics. As the shortage of doctors worsens, waiting times for catheter placement have increased. The implementation of the 'Transfer of competence: nurse-led central venous catheter insertion' cooperation protocol in 2016, in the Paris hospital trust (AP-HP), has enabled these waiting times to be reduced without any increase in the frequency of complications or effects on the safety of the procedure.